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Dr. White was assistant dean for medical education, University of Michigan Medical School, Ann Arbor, Michigan, when this article was written. She is now associate dean and associate professor for medical education, University of Virginia School of Medicine, Charlottesville, Virginia.

Abstract

Although physicians and nurses play critical roles in providing team-based collaborative care, the literature on current relationships between physicians and nurses in typical health care settings reveals troublesome characteristics that affect the quality of the patient care that they provide. Studies report communication failures, poor coordination, and fragmented care within and across organizations, which then have been associated with medication errors, patient safety issues, and patient deaths. Because the physician–nurse relationship is a critical component of a high-functioning patient care team, curricular interventions are needed to improve communication between physicians and nurses and to avoid professional conflict that can potentially compromise the quality of the patient care they offer.

Currently, medical schools provide students with limited education and training on the roles of other health care professionals. In 2009, to begin addressing this need in the curriculum, the authors implemented a nurse-shadowing program at the University of Michigan Medical School. They set out to help first-year medical students learn more about the role of nurses in health care to positively influence their attitudes toward nurses and improve their understanding of nurses’ roles in health care teams. Pre- and postprogram survey results revealed that medical students’ attitudes toward nurses improved and their knowledge of the profession increased as a result of this intervention. In this article, the authors provide a description of the half-day program, evidence of its effectiveness, the implications of those findings, and future directions for teaching medical students about effectively working on interprofessional teams.

Physicians and nurses are central members of today’s health care teams; in fact, the literature increasingly has proven that physician–nurse relationships greatly affect the quality of the patient care that they provide. Successful physician–nurse collaboration has been associated with positive patient outcomes in intensive care unit settings1–3; however, other studies revealed troublesome characteristics about current physician–nurse relationships in other health care settings that negatively affect patient care. These studies reported communication failures, poor coordination, and fragmented care within and across organizations,4–7 which then have been associated with medication errors, patient safety issues, and patient deaths.8,9

Physicians and nurses also do not acknowledge these deficiencies to the same degree. Thomas and colleagues,10 in a survey of critical care physicians and nurses exploring their attitudes toward teamwork, found that 73% of physicians and just 33% of nurses rated the quality of their collaboration and communication as high or very high. In contrast to physicians, nurses reported difficulty speaking up and disagreements not being appropriately resolved, and, in situations for which more input was needed for decisions, nurses’ input was not well received. The authors attributed these differences between physicians and nurses to variations in their status/authority, responsibilities, training, and nursing and physician cultures.

Weinberg and colleagues11 noted many of these differences between nurses and physicians-in-training as well. Their study showed that residents were more likely than physicians to work collaboratively with nurses, although, when asked about their relationships with nurses, the residents’ answers varied widely. These authors also found that the degree of mutual respect between residents and nurses seemed dependent on both the level of education that the residents perceived the nurses to have attained and the extent to which the nurses observed the traditional medical hierarchy. However, residents exhibited some confusion between different nursing degrees and about the relationship of those degrees to the nurse’s role on the team. The authors further reported that the interdependency between residents and nurses was commonly characterized as “residents gave orders that nurses carried out.” The authors concluded that the relationships between residents and nurses significantly influenced residents’ future attitudes toward working with nurses.

Elder and colleagues12 also demonstrated this pattern of trainees’ attitudes toward nurses affecting future practice habits in medical students. As medical students advance in their careers, their ethical attitudes stay the same or worsen, as measured with regard to beneficence, autonomy, justice, morality, and doctors’ rights and obligations. Therefore, we argue that physicians’ attitudes toward physician–nurse relationships that are formed early in training also will stay the same or worsen. Because the physician–nurse relationship is a critical component of a high-functioning patient care team, early and ongoing curricular interventions in medical school are necessary to improve communication between physicians and nurses and to avoid professional conflict that can potentially lead to poor relationships that negatively influence the quality of patient care.

Such initiatives within health systems have focused on reducing ambiguity about the role of nurses on health care teams13 and promoting better communication and coordination between practicing nurses and physicians.14 Exposure during medical school to a nurse’s role on the patient care team provides an early and potentially more influential foundation of understanding to build on as medical students progress through their training. However, how to expose medical students to other health care professions is a significant challenge in medical education today. Many medical educators argue that there is already insufficient time in the four-year curriculum to teach essential content in the biomedical and clinical sciences. Thus, any curricular changes must be flexible and able to achieve the desired results in short periods of time. We exposed first-year medical students at the University of Michigan Medical School to the roles of nurses in health care through a four-hour shadowing experience. We then investigated the impact of this intervention on medical students’ knowledge of the roles of nurses as well as their attitudes toward and understanding of the contributions of nurses to the health care team.

About the University of Michigan Medical School Nurse-Shadowing Program

In 2008, we piloted a four-hour nurse-shadowing program with 20 first-year medical students on a volunteer basis. For this program, we defined a nurse as a health care professional who engaged in clinical activities and met the standards of education and clinical competence required of the RN degree. The chief of nursing services agreed to arrange for these 20 medical students to shadow nurses in the University of Michigan Health System. The medical students were added to an existing shadowing program that was originally created for nursing students to shadow practicing nurses. The medical students who participated in the pilot project reported an educational and fulfilling experience and approached the curriculum committee at the University of Michigan Medical School to request that the shadowing program be added to the curriculum for all first-year medical students. The administration agreed that the program was valuable and offered a novel experience for students, and, in 2009, all 167 first-year medical students participated in a required four-hour nurse-shadowing program. We set two learning objectives for this intervention: At the end of the session, students should be able to (1) understand what nurses bring to the health care team and (2) communicate effectively with a nurse.

The medical school and the school of nursing collaborated on this program. Medical students were allowed to select a nurse to shadow from a variety of specialty services (pediatrics, emergency medicine, etc). The students ranked their preferences and then were assigned to a particular specialty and informed when and where they should meet the nurse whom they were going to shadow. The nurses were aware of the project and enthusiastically volunteered to participate. Nurses to whom students were assigned were asked to meet their medical students at a particular time and location on the ward of the hospital or in the clinic where they worked. The nurses were given clear instructions to engage the medical students in assisting them as they completed their typical tasks on a regular shift, to answer any questions that the medical students had, and to ensure that the students stayed for the entire four-hour shift. Although students shadowed different nurses in different specialties and in different practice locations, the instructions that we gave to the nurses were standard, so we considered the students’ experiences to be essentially comparable.

To assess the impact of the nurse-shadowing program, students took pre- and postprogram surveys, including questions related to their attitudes toward nursing, communication patterns with nurses, roles of nurses on a health care team, interprofessional relationships, and knowledge of nurses’ training and education. All responses to the pre- and postprogram surveys were both anonymous and confidential. The University of Michigan Medical School institutional review board deemed our study exempt from ethical review. We analyzed the survey results using descriptive statistics (totals, means, and standard deviations) and pre- and postprogram survey comparisons (paired sample t tests) in PASW/SPSS Version 18 (Chicago, Illinois).

Initial Impact of the Nurse-Shadowing Program

Overall, the program had a positive impact on the medical students. Combining the “agree” and “strongly agree” responses from the postprogram survey, 139 of 167 (83%) medical students indicated that the nurse-shadowing program was a valuable part of their medical education. One hundred thirty-four of 167 students (80%) reported an increased openness to learning from nurses, 132 (79%) reported an increase in their knowledge about what nurses bring to the team, and 125 (75%) reported a significant increase in respect for the knowledge and skills of nurses. Slightly more than half the class (95 of 167; 57%) reported an increase in their ability to communicate with nurses.

Comparisons of pre- and postprogram survey responses indicated that, in many areas, students’ attitudes toward nurses and nursing became more favorable and their self-assessed knowledge about nursing increased as a result of the program. On items related to the role of nurses relative to physicians on health care teams—questions regarding decision-making power, assessing the psychosocial needs of the patient, amount of time spent with patients, and the relative importance of the profession’s role in providing patient care—students’ responses showed a statistically significant shift in favor of nurses (paired t tests yielded P values between .000 and .013 for these items, with small to moderate Cohen d effect sizes in the 0.20 to 0.35 range). Responses to questions on interprofessional curricula also showed similar, favorable statistically significant changes (paired t tests yielded P values between .000 and .014, again with small to moderate Cohen d effect sizes in the 0.20–0.37 range). Finally, when asked to self-assess their knowledge regarding nurses’ training, types and roles of nurses, licensing and responsibilities, and nurse–physician collaboration, students’ responses showed statistically significant increases (paired t tests yielded highly significant P values < .001, with moderate to large Cohen d effect sizes in the 0.42–0.72 range).

Still, our study had several limitations. First, it is difficult for us to know the long-term effects of the program on medical students’ knowledge and particularly on their attitudes. The first class in 2009 completed the postprogram survey within a week of finishing the program. We will base longer-term evaluations on their self-report of the influence of this first-year experience on their attitudes toward and their professional relationships with nurses. Second, in using self-reported data, we had to assume that the students’ responses were honest and accurate.

In the future, we plan to assess the impact of this experience on the nurses who participated to allow us to see whether their attitudes toward medical students and interprofessional communication also changed with this experience. In addition, we hope to evaluate the actions of the medical students and nurses to supplement this evaluation of their attitudes.

Implications of the Nurse-Shadowing Program

Researchers have already proven that what students learn in medical school creates a foundation for their future behaviors. For example, exposing students to community service in medical school has been shown to predict their involvement in community service after graduation.15–17

Through the pre- and postprogram surveys, we were able to gather evidence that medical students’ attitudes toward nurses improved and their knowledge of the many roles of the nursing profession in the delivery of health care increased—in many cases significantly—as a result of the nurse-shadowing program early in medical school. From these data, we were also able to conclude that a nurse-shadowing program for medical students can set the foundation for students to cultivate positive interprofessional attitudes, with the intent that eventually these attitudes will contribute to more effective collaborations between nurses and physicians. However, two findings—that 57% of students reported an increased ability to communicate with nurses and that 75% reported significantly more respect for the knowledge and skills of nurses—indicate that this program may be more effective in increasing knowledge and improving attitudes than in teaching practical communication skills.

Although we saw improvements and positive changes in medical students’ attitudes and knowledge, we also saw opportunity for further education. Mentoring and role modeling are critical tools, particularly when intended learning outcomes are based on attitudes. As in the community service example mentioned above, medical students reported that their mentors and role models significantly influenced their commitment to community service.18 We believe that the same is true for students’ knowledge about and respect for colleagues in different health professions. The absence of supportive mentoring and the presence of negative role modeling that demonstrate the opposite of the attitudes and behaviors we want our students to embrace can undo the strong foundation laid in medical school.19 If we want our students to show respect for and willingness to collaborate with members of health care teams from different health professions, we must continuously reinforce and model these behaviors ourselves.

Going Forward

On the basis of the responses of the students who completed our pre- and postprogram surveys, this four-hour nurse-shadowing program has become a requirement for all first-year medical students at the University of Michigan Medical School, who must complete it before they can advance to the second year. We reached the decision to make this program a requirement partly because of the results of these surveys and partly to support both the medical school’s relationship with the nursing school and its dedication to interprofessional activities. We plan to continue to monitor the effectiveness of the program and to make adjustments as needed. Furthermore, we plan to explore the longitudinal effects of the program to determine whether it positively influences longer-term attitudes toward nurses and nursing. Our intent is to resurvey medical students in their second, third, and fourth years to monitor how their responses to the survey change over time. Lastly, we plan to expand this interprofessional education initiative to improve the relationships among all members of the health care team, such as pharmacists and social workers. Overall, our experiences have taught us that improving the relationship between physicians and nurses is important to fostering quality patient care and should be addressed early in the careers of physicians-in-training.

Acknowledgments: The authors wish to thank Dr. Robert Lash and Dr. Raj Mangrulkar for their assistance with the editing of this manuscript.

Funding/Support: None.

Other disclosures: None.

Ethical approval: The University of Michigan Medical School institutional review board deemed this study exempt from ethical review.

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